Nutrition in Clinical Practice最新文献

Background: Prolonged fasting before surgery remains common despite guidelines recommending liquid fasting for 2 h and solid fasting for 6 h preoperatively. Consuming carbohydrate-rich drinks until 2 h before surgery improves patient well-being and reduces postoperative complications and insulin resistance. Given the persistence of implementation barriers, including logistical challenges and insufficient patient education, this study aimed to implement drinking up to 2 h before elective orthopedic surgery.

Methods: The Grol and Wensing implementation approached was followed in a before-after study conducted at a Dutch academic orthopedic ward (April 2023 to May 2024), after approval by the Scientific Ethical Committee. Current practices and barriers were assessed, and tailored strategies were developed using implementation theory and taxonomies to develop implementation strategies for the identified factors, followed by integration and evaluation.

Results: Implementation included dissemination, patient-oriented, organizational, educational, and risk prevention strategies. A total of 39 patients participated in the initial analysis and 48 patients participated in the evaluation. Preoperative fasting from liquids significantly reduced from 8:20 h (IQR: 4:42-12:19 h) to 4:38 h (IQR: 2:58-6:12) by informing patients about the importance of drinking up to 2 h before surgery and to 2:45 h (IQR: 2:21-3:26) by facilitating drinking lemonade after admission when surgery would start in ≥2 h. Patients' comfort improved regarding thirst, whereas no effect was found for other symptoms. Adverse events, including postponement of surgeries and pulmonary aspirations, during surgery did not occur while accepting >1 h of fasting at the start of surgery.

Conclusions: Scalable implementation strategies for patient education on fasting and coordinated provision of lemonade reduced fasting duration among elective orthopedic patients.

Background: This project aimed to develop an evidence-based nursing care bundle after gastrostomy feeding tube insertion and implement it into clinical practice using the Knowledge to Action (KTA) framework.

Methods: This mixed-method design project was conducted in a university hospital between December 2021 and June 2022. The project was carried out in four phases: (1) development of an evidence-based care bundle, (2) education for care bundle training, (3) implementation of the care bundle, (4) evaluation of the care bundle. Nurses' compliance with bundles was measured using All-or-None measurement. The analysis of the qualitative interview conducted was performed using the content analysis method of Graneheim and Lundman.

Results: The developed Sezer gastrostomy care bundle consists of three parameters (peristomal area care, tube feeding, and medication administration through the feeding tube) and a total of 14 elements to be applied by nurses under these parameters. Compliance rates for peristomal area care, tube feeding, and medication administration through feeding tube parameters were 100%, 98.66%, and 98.66%, respectively. Two themes and six subthemes emerged: (1) reflection of using the Sezer gastrostomy care bundle on nursing care and (2) adoption of Sezer gastrostomy care bundle.

Conclusion: The gastrostomy care bundle was developed in accordance with the Institute of Healthcare Improvement's recommendations. The KTA framework provided an appropriate structure to transform evidence into practice, meticulously address barriers, evaluate outcomes, and ensure sustainability. The project found that nurses complied with all its parameters. Studies evaluating the effect of the gastrostomy care bundle on patient outcomes are recommended.

Implementation science (IS) offers a structured approach to bridging the gap between research and practice by facilitating the adoption of evidence-based interventions (EBIs). One established framework within IS is the Quality Enhancement Research Initiative (QUERI), developed by the US Department of Veterans Affairs. QUERI promotes the active dissemination of EBIs through a phased roadmap: preimplementation (data to knowledge), implementation (knowledge to performance), and sustainment (performance to data). This review article explores the QUERI framework in depth and its application in clinical nutrition settings. Two case studies illustrate how QUERI can enhance implementation efforts: (1) improving inpatient malnutrition screening and (2) integrating outpatient surgical prehabilitation programs. In the first case, QUERI guides the identification of low screening and diagnosis rates, stakeholder engagement, toolkit development, and ongoing evaluation to ensure sustainability. In the second, QUERI aids in developing and adapting evidence-based prehabilitation protocols while balancing fidelity and customization to local workflows. Both examples demonstrate the importance of structured planning, stakeholder involvement, and iterative evaluation in achieving sustained change. QUERI's emphasis on choosing a high-volume or high-risk problem, defining best practices, and documenting outcomes makes it a valuable tool for nutrition professionals aiming to improve outcomes through consistent application of EBIs. As clinical nutrition continues to evolve, implementation frameworks like QUERI offer a practical pathway for translating research into impactful, sustainable improvements in patient care.

Hospitalized very preterm infants, those born at <32 weeks of gestation, represent a nutritionally vulnerable population. Anthropometry is used widely in neonatal intensive care unit (NICU) clinical and research settings to facilitate nutrition assessment. This approach involves measuring an infant's body weight, length, and head circumference and plotting them on a growth chart to assess current nutrition status and monitor changes over time. Anthropometric measurements are prone to error owing to the challenges of measuring sick infants who frequently require respiratory support and other medical equipment and a lack of standardized approaches. In this paper, we describe our standardized approach to anthropometry in hospitalized very preterm infants in the NICU with a focus on addressing the specific challenges that arise in this environment. Our overall goal is to provide a tool for clinicians and researchers who want to enhance the quality of anthropometric data, improve decision-making about diet-based care in the NICU, and strengthen the conclusions and impact of research involving very preterm infants.

We conducted a quality improvement (QI) initiative to increase documentation of energy goals within 48 h of admission to the pediatric intensive care unit (PICU) for all children. Malnutrition remains one of the most prevalent issues in the PICU. Research shows early estimation and documentation of energy goals in the electronic health record (EHR) is associated with higher daily energy intake. Energy goals are often not documented early in patient admission, which can be improved. By revising critical care progress notes to prompt providers to estimate an energy goal when no goal has been documented within the first 48 h we expected an increased rate of goal documentation. A QI initiative was performed from May 2021 to April 2022 using the Plan-Do-Study-Act methodology. Interventions included (1) an automated smart-text element on the EHR progress note template and (2) a review of calculated and documented energy goals in calories by registered dietitians. A review team monitored the rate of documentation of energy goals monthly. Before the QI interventions, the baseline rate of documentation of an estimated energy goal was 44%. After adding standardized prompts to the EHR system, the rate of a documented energy intake goal within 48 h of admission by critical care providers increased to >90%. Using automated prompts in EHRs resulted in an increased frequency of energy goal documentation exceeding 90% monthly. Establishing a standardized prompting system within the EHR directly led to an overall increased frequency of energy goals documented in calories.

Quality improvement is utilized to improve system issues within healthcare. Although many models have been identified for quality improvement, the Plan-Do-Study-Act (PDSA) model is used commonly. The PDSA cycle is a quality improvement tool that has produced numerous system-wide changes. Since its conception, the PDSA has been used in a variety of nutrition-related quality improvement initiatives. Furthermore, the PDSA cycle has been applied in implementation science to bridge the gap between the literature and clinical nutrition practice. Implementation science using the PDSA cycle can be beneficial in the introduction of the Global Malnutrition Composite Score (GMCS) to identify, diagnose, and treat malnutrition in hospitalized patients. This manuscript describes the PDSA cycle in detail with direct application to GMCS implementation.

Background: A broader project translated evidence for a Mediterranean-style dietary pattern (MDP) into clinicians' routine dietary care for type 2 diabetes and coronary heart disease in a public health service in Australia. This study aimed to determine sustainment of practice and what predicts clinicians' routine use of an MDP approach 2 years after facilitated implementation.

Methods: May 2021-October 2022 implementation strategies targeted multidisciplinary clinicians involved with dietary care. In October 2024 clinicians were surveyed using an adapted 14-item Normalization Measure Development (NoMAD) questionnaire. Sustainment was defined as self-rating ≥7 on a scale from 0 (not at all) to 10 (always) that recommending MDP is a "normal part of your work." Exploratory analyses, including logistic regression, identified whether clinician characteristics, NoMAD items, and theoretical constructs predicted sustainment.

Results: Six dietitians and 61 other clinicians completed surveys, of which 100% and 52% self-reported MDP practice sustainment, respectively. Multivariable models in the total cohort found that the odds of sustainment increased with higher scores in NoMAD items related to the perception that using an MDP approach was legitimately within the clinicians' role (odds ratio [OR], 15.7; 95% CI, 3.23-224), shared understanding of supporting evidence (OR, 3.79; 95% CI, 1.35-15.8), and the constructs cognitive participation (OR, 6.12; 95% CI, 1.78-27.9) and collective action (OR, 5.7; 95% CI, 1.48-30.1). Twenty-seven clinicians commenced in the setting ≤2 years prior; within this group, MDP practice sustainment was significantly higher if MDP handover/orientation was received (71% vs 29%, P = 0.012).

Conclusion: These data provide novel insights into impacts on sustainment of implemented evidence-based dietary practice in the context of a multidisciplinary workforce with high turnover.

Background: Vitamin C deficiency (VCD) is common in adult inpatients in high-income countries and is associated with moderate to severe frailty, cognitive impairment, and scurvy signs and symptoms. However, clinical practice associated with vitamin C status has not been explored in this setting. This study aims to describe current vitamin C clinical practices and explore barriers and enablers that influence nutrition care delivered to adult hospitalized patients within routine clinical practice.

Method: This study was conducted across General Medicine units at a tertiary health service in Melbourne, Australia. Using an explanatory, sequential mixed methods design, data across each stage of the Nutrition Care Process (NCP) was triangulated from three phases involving analysis of clinical guidelines, file review data of patients with VCD (n = 100) according to plasma vitamin C levels, and focus groups informed by the Theoretical Domains Framework.

Results: Triangulated data revealed that barriers to vitamin C nutrition care include infrequent assessment, influenced by environmental factors, beliefs about consequences, clinical priority, and healthcare professionals' (HCPs') knowledge. Enablers include strong belief in nutrition care capability and belief that vitamin C nutrition care is within HCPs' roles. Low suspected VCD diagnosis and low intervention and discharge planning rates were also observed. The single vitamin C clinical guideline lacked detail across specific stages of the NCP.

Conclusion: Limited vitamin C nutrition care potentially occurs in adult inpatients, hindered predominantly by assessment barriers. To achieve improvements in clinical practice, a theoretically driven implementation strategy targeted to healthcare systems, clinician behavior, and national quality standards is required.